CLM-2026-020014
Harbor Family Practice, Family Medicine. Service 2026-08-11 at office (POS 11). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Patrick Fisher
- Member ID
- UHC-27825-83
- Date of birth
- 1985-08-03
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-415987
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7287
- Coverage period
- 2021-10-01 to 2026-04-23
- Deductible
- $683.28 of $3,500.0020%
- Out-of-pocket maximum
- $4,235.75 of $14,000.0030%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3348247230
- Network
- In network
- Rendering NPI
- 8310528301
- Location
- Austin, TX · TIN 89-3690484
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 90471 | Immunization administration | — | 1 | 1 | $29.00 | $17.98 | — | — | DeniedCO27 |
| Totals | $29.00 | $17.98 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-986627
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008563 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-11 is after coverage terminated on 2026-04-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Family Practice (3348247230). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Family Practice2026-08-11 15:49
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-09-06 01:00
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-06 11:11
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-11 is after coverage terminated on 2026-04-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020373 | 2026-07-12 | Unity Primary Care Associates | $2,840.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.